Table of Contents
1
Executive Summary
2
Population Health Management
3
A Framework Is Key to Riding the Waves in Unchartered Waters
4
Every Individual Is Unique, and We Must Respect That
5
Strategy, Strategy, and Strategy
6
Cross-Departmental Interaction
7
Prediction is not harmful: neither for the patient nor for the payer
8
Power of Predicting Risk Score
9
Wanted: Population Management Specialist Bots. Immediate Joining
10
Chatbots Implementation Strategy
11
Case Study: End-to-End Population Health Management Product Creation
12
Conclusion
Executive Summary
Executive Summary
Healthcare payers are worried about the rising costs per enrollee. Any measure to curb costs might damage member experiences, leading to dis-enrollment. Hence it is crucial for health plans to focus on an approach of reducing costs that don’t break the member relationship. In fact, the cut-throat competition among payers in the US healthcare market is pushing business teams in payer offices to think beyond conventional methodologies and get creative.
Population Health Management
Population Health Management
Now, let’s turn to the most discussed and acclaimed concept among the payer network – The Population Health Management. It focuses on the discovery of patient’s present and historical health, and socio-economic conditions. Data is everywhere; it resides in patient health records in EHR; it lies in claims information; it lies in laboratories and many other touchpoints. Collection of data is critical, but collection alone doesn’t satiate our need to reduce costs and improve member experiences.
A Framework Is Key to Riding the Waves in Unchartered Waters
A Framework Is Key to Riding the Waves in Unchartered Waters
Implementation of Population Health Management is a big challenge, indeed, as it involves payer departments, members, and providers at various levels. The quest for simplifying the implementation led to the creation of a smart framework that can help payers to focus on key areas.
A small population of members drives the majority of healthcare costs. Although accurate identification and categorization of members is just the starting step, it is critical in creating the roadmap for dealing with possible member healthcare costs and experiences. The internal departments of payers should act more connected than before to ensure a free-flow of member information, bringing in a 360-degree view of the member’s condition.
Most health plans consider this as an internal exercise, but involving the member will do more benefit to the program. Members should be aware of key initiatives and efforts of the payer to improve health by regular monitoring. This awareness helps in sourcing key data specific to socio-economic conditions, which are rarely captured in the clinical visits. The framework will be applicable for members enrolling in various types of plans like Medicare, Medicaid, commercial, or group health insurance. However, it is critical to consider the member’s demographic information while categorizing for risk calculations, accordingly direct the member to correct the department that can help members to improve health.
Every Individual Is Unique, and We Must Respect That
Every Individual Is Unique, and We Must Respect That
The first step for successful implementation of population health starts with accurately understanding the member health condition by not limiting to the clinical data available over EMR and claims data but by stretching to obtain family level health conditions and social determinants of health. It is not difficult to assimilate clinical data with the advent of EMR and FHIR API resources, but more efforts are required to gather accurate data on socio-economic factors.
Member profiling involves Risk Stratification of members based on behavioral conditions, chronic conditions, physical conditions, emergency department visits, and socio-economic factors. Members are categorized as High Risk, Medium Risk, Low Risk, and Healthy using these factors. Risk scoring will take all these factors to arrive at the segregation of members, but adopting predictive models in liaison with conventional risk scoring acts as the differentiators that can show a direct impact on the payer’s bottom-line costs of managing a member
It is essential to focus on members who consume more healthcare resources and claim frequently. However, it is crucial to keep the population categorized as healthy to stay healthy consistently. Most of the time, dealing with high-risk members is planned. They were given enough attention and support to ensure a reduction in costs and maintaining health. Consider the case of a healthy member falling sick and slowly moves into the high-risk band leading to an increase in cost and operational efforts. Predictive analytics plays a key role in helping the payers in keeping track of the patients who might move from healthy to high-risk levels.
Strategy, Strategy, and Strategy
Strategy, Strategy, and Strategy
As the members enrolling in the plan increases or if the plan currently handles millions of members, then care management needs more reliable data to act immediately. Each internal department in the payer office should have a 360-degree view of the member that details out each action performed by any other department on the member. This information helps the corresponding team to direct members or intervene at the required level.
Cross-Departmental Interaction
Cross-Departmental Interaction
While case managers deal with high-risk patients and reduce the costs, disease managers focus on handling the chronic conditions that might become acute, thereby thrusting the patient to admit into a hospital or have emergency department visits. The majority of the population, health management tools, stop at the level of establishing strong communication between case management and disease management teams. Although this sounds complete, one piece of the puzzle is still missing.
Industrial and Manufacturing (General Electric)
Prediction is not harmful: neither for the patient nor for the payer
Prediction is not harmful: neither for the patient nor for the payer
Predictive analytics is still not seen as a go-to option for the majority of payers. Certainly, adopting predictive analytics may not yield immediate results. However, it must be noted that the late adoption will only leave the payers losing the race to competitors. Especially to gain an advantage in population health implementation, payers should not hesitate to try out predictive analytics-driven models that improve the overall healthcare experience of members.
Power of Predicting Risk Score
Power of Predicting Risk Score
There are three stages in the reduction of costs in re-admissions
Prediction of Re-Admission: With the help of demographic, socioeconomic, and clinical factors, payers can reasonably predict the possibility of re-admission. The action plan is to ensure regular monitoring of high-risk patient re-admissions and automate the workflow to outreach to avoid readmission.
Recovery Planning: We cannot avoid a patient’s re-admission every time. Still, it is essential to ensure the patient recovers quickly by monitoring the treatment course and providing the necessary guidance during a hospital stay. This helps in improving the experience and tracking the high-cost medication or procedures performed to the patient.
Discharge Planning: It is essential to have a probable length of stay. This can be predicted based on the patient’s admission history for similar conditions. A utilization management nurse can help in reducing the length of stay in a hospital, thereby reducing the overall costs.
Wanted: Population Management Specialist Bots. Immediate Joining
Wanted: Population Management Specialist Bots. Immediate Joining
The critical judge for determining the success of population health management is the enrolled member. Although the measures taken by payers show improvement in the bottom line with a reduction in healthcare costs, the goal of improving patient experience fails to meet the member expectations. Payer needs to communicate the member’s importance to the plan and provide personalized care that acts as a key point of difference when compared to other insurance payers in the market.
Chatbots Implementation Strategy
Chatbots Implementation Strategy
At every touchpoint, the enrollee carries the experience that creates conscious and subconscious patterns in the brain, which, in turn, determines their next purchase or advocating about their experience to others. An enrollee’s satisfaction is driven by the swift flow of information that allows faster decisionmaking.
Chatbots can play various roles like plan finder, enrollment assistant, appointments manager, care coordinator, customer service executive, etc. They are intelligent to learn based on earlier conversations and improvise the patient experience to new levels of customized care.
Case Study: End-to-End Population Health Management Product Creation
Case Study: End-to-End Population Health Management Product Creation
Problem Statement: The client has an aspirational objective to evolve to the best health plan in State by offering the most personalized service to all enrolled members and improve their satisfaction rate with an economical budget.
The following workflow is embedded into the device-agnostic web application:
- Configurable and Dynamic Member Risk Assessment
- Automated Member Assignment
- Integrated Care Management
- Personalization of Care
- Financial and Clinical Outcome Analytics
Any new member enrolled in the plan will flow through the predictive algorithm. It determines whether the member should be assigned for a quick assessment or for the member management team for fetching socio-economic factors. For all existing members, the clinical data from various touchpoints in the provider’s office is continuously pushed into the algorithm. This helps in understanding the current health risk of the member and accordingly assigns to the appropriate user in the medical management team.
After the auto-assignment of a member, the medical management team creates a case, completes assessment forms, and understand HEDIS compliance data to create the care map. The member is always at the center of the action plan to ensure that they remain abreast of all important communications. Any hospital admission or emergency visit of members alerts the medical management team and directs the case to get handled by an appropriate user. The client observed efficient utilization of internal resources that now focus on improving the healthcare experience for members. A chatbot integrated with the member profile helps the member to access care easily by one touch appointment bookings, closing claim inquiries, searching for nearby providers, resolve any questions related to planning benefits. By linking each interaction with members to financial and clinical benefits quantifies them, and results in outcomes like preventable re-admission and ER visits.
This solution had a high level of automation, analytics, and predictive capabilities incorporated in each workflow. This approach enabled the client to utilize population health management applications with ease and helped reduce the learning curve to deploy this application enterprise-wide. The Azure-hosted web application is made accessible in all devices with customized views.
Conclusion
Conclusion
The population health management platform gives payers the power to make meaningful and quantifiable decisions that aid significant cost reductions. Besides cost savings, it also helps insured members to experience the desired quality of service whenever needed. The better the patient experience, the easier it becomes for the payer to retain the member and meet their growth goals.
It is critical to partner with a technology partner who has deep domain expertise in both creation, implementation, and support for population health management applications. If there is an existing application that is partially helping to make up to population health management or disparate applications that operate in silos for each care division, then it is the right time to take the next step in integrating the multiple source systems and create a 360-degree view of member profiles, which helps the medical management team discover the true power of informed decision-making.
Contributor
Pavan Seepana
Senior Consultant
About ACS
ACS Solutions is a leading global information technology services and consulting organization with 20,000+ employees and has been serving businesses across industries since 1998. A trusted partner to both mid-market and Fortune 500 clients globally, ACS Solutions has been instrumental in each of their unique digital transformation journeys. Our extensive industry-specific expertise and passion for innovation have helped clients envision, build, scale, and run their businesses more efficiently.
We have a proven track record of developing large and complex software and technology solutions for Fortune 500 clients across industries such as Retail, Healthcare & Lifesciences, Manufacturing, Financial Services, Telecom and more. We enable our customers to achieve a digital competitive advantage through flexible and global delivery models, agile methodologies, and battle-proven frameworks. Headquartered in Duluth, GA, and with several locations across North and South America, Europe and the Asia-Pacific regions, ACS Solutions specializes in 360-degree digital transformation and IT consulting services.
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